Inquest into the Death of TP (a child) (Subject to a Suppression Order)

Inquest into the Death of TP (a child) (Subject to a Suppression Order)

Delivered on :4 May 2016

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : YesSuppression of the deceased child’s name from publication and any evidence likely to lead to the deceased child’s identification. Suppression of the name of any other person referred to who is or has been the subject of a protection order.

Summary : The deceased child was 15 years old when she died on 9 December 2011 at Sir Charles Gairdner Hospital, having been conveyed there by ambulance from Hale School where she was attending the Hale School Sony Camp for special needs children. The deceased died on the second night of her attendance at the camp after a seizure. The deceased had suffered epileptic seizures throughout her life for which she required medication and medical reviews on a regular basis.

Immediately before her death the deceased was subject to a Protection Order pursuant to the Children and Community Services Act 2004 and an inquest was mandated. The focus of the inquest was on the deceased’s medical needs, the provision of information concerning her medical needs to staff members at the Hale School Sony Camp, and the management of her medical needs whilst at the camp.

The State Coroner found that the deceased’s death was consistent with seizure disorder (epilepsy) with associated vomit aspiration and death occurred by way of natural causes. The deceased’s death is to be considered in the context of “Sudden Unexpected Death in Epilepsy” (SUDEP), an uncommon but well recognised phenomenon. The medical treatment that the deceased had received over the years was of a very high standard but the nature of her disorder was such that despite all treatment it had not been possible to predict when a seizure would occur or what the consequences would be.

The State Coroner commended those involved in holding the Hale School Sony Camp, she made comments about medical clearance for future camp participants and she urged continuation of active research in the in the area of SUDEP. The State Coroner was satisfied that the supervision, treatment and care by the Department for Child Protection and Family Support was proper and appropriate to the deceased’s needs.